Mental Health Appointments Research Articles

Non-Attendance in Randomized Remote Mental Health Clinical Trial During the COVID-19 Pandemic

During the COVID-19 pandemic, a significant increase in psychiatric symptoms was found among essential service professionals (professionals or interns from the health and educational sector) who were exposed to high-risk contamination areas. These symptoms impair functionality, impacting quality of life, work, autonomy, and relationships. Recent data show that brief interventions are effective; however, between 20 and 30% of those individuals often do not attend their scheduled appointments. This study aimed to identify variables related to non-attendance for remote telepsychotherapy among participants with COVID-19-related emotional distress compared to those who initiated treatment. We included 2097 essential service professionals with PROMIS (Patient-Reported Outcomes Measurement Information System) T-scores ≥70 for anxiety, depression, or irritability who scheduled a remote mental health appointment. Participants completed clinical and sociodemographic data, mental health risk and protective factors, and PROMIS subscales. We conducted a binary logistic regression, using attendance vs. non-attendance as the dependent variable and these demographic and clinical characteristics as independent variables. Of the 2097 participants, 230 (11%) did not attend the first session despite three rescheduling attempts. Non-attendance was associated with the presence of irritability and seeking treatment during the second COVID-19 wave. In contrast, anxious symptoms, older age, and coping mechanisms that typically include intellectual and reading activities were associated with attendance. Our findings shed light on non-attendance patterns in mental health services, revealing that personal characteristics and environmental factors significantly contribute to missed appointments. Understanding these dynamics can improve patient engagement and adherence to mental health treatments, particularly in the context of telepsychotherapy during the COVID-19 pandemic.

Influence of parental education on care patterns of children with attention deficit hyperactivity disorders in Indonesia

Severe disparities in the care of children with Attention Deficit-yperactivity Disorder (ADHD) against the background of financial stability and parental demographic areas are major public health challenges in Indonesia. This study was designed to investigate how parental education influences care pattern of children with ADHD. We carried out interventions in the form of counseling and assistance regarding the care of ADHD children in the family. Of the 70 children included in the study, 33 (47.1%) did not attend mental health appointments and 51 (72.9%) did not receive any treatment at 3 to 6 month follow-up. Logistic regression showed that increasing age and medication problems were associated with fewer follow-ups on mental health appointments (P < 0.05) and less treatment utilization (P < 0.05). The results of this study implicated that the higher the educational background the parent has, the more adequate treatment the ADHD children receive. This is the fact that care patterns are likely dependent on parental education’s status. Further study on which factor between financial status and socio-demographic that has higher impact on ADHD children’s parents and coping style should be conducted.

Clinical Use of Mental Health Digital Therapeutics in a Large Health Care Delivery System: Retrospective Patient Cohort Study and Provider Survey.

While the number of digital therapeutics (DTx) has proliferated, there is little real-world research on the characteristics of providers recommending DTx, their recommendation behaviors, or the characteristics of patients receiving recommendations in the clinical setting. The aim of this study was to characterize the clinical and demographic characteristics of patients receiving DTx recommendations and describe provider characteristics and behaviors regarding DTx. This retrospective cohort study used electronic health record data from a large, integrated health care delivery system. Demographic and clinical characteristics of adult patients recommended versus not recommended DTx by a mental health provider between May 2020 and December 2021 were examined. A cross-sectional survey of mental health providers providing these recommendations was conducted in December 2022 to assess the characteristics of providers and recommendation behaviors related to DTx. Parametric and nonparametric tests were used to examine statistical significance between groups. Of 335,250 patients with a mental health appointment, 53,546 (16%) received a DTx recommendation. Patients recommended to DTx were younger, were of Asian or Hispanic race or ethnicity, were female, were without medical comorbidities, and had commercial insurance compared to those without a DTx recommendation (P<.001). More patients receiving a DTx recommendation had anxiety or adjustment disorder diagnoses, but less had depression, bipolar, or psychotic disorder diagnoses (P<.001) versus matched controls not recommended to DTx. Overall, depression and anxiety symptom scores were lower in patients recommended to DTx compared to matched controls not receiving a recommendation, although female patients had a higher proportion of severe depression and anxiety scores compared to male patients. Provider survey results indicated a higher proportion of nonprescribers recommended DTx to patients compared to prescribers (P=.008). Of all providers, 29.4% (45/153) reported using the suggested internal electronic health record-based tools (eg, smart text) to recommend DTx, and of providers recommending DTx resources to patients, 64.1% (98/153) reported they follow up with patients to inquire on DTx benefits. Only 38.4% (58/151) of respondents report recommending specific DTx modules, and of those, 58.6% (34/58) report following up on the impact of these specific modules. DTx use in mental health was modest and varied by patient and provider characteristics. Providers do not appear to actively engage with these tools and integrate them into treatment plans. Providers, while expressing interest in potential benefits from DTx, may view DTx as a passive strategy to augment traditional treatment for select patients.

Living with Parkinson's disease in Portugal: Findings from PRISM study

BackgroundParkinson's disease (PD) ranks second in global neurodegenerative disorders. The “Parkinson's Real-world Impact assesSMent (PRISM)” study addressed the disease burden and treatment of European PD patients. Yet, the burden on Portuguese PD patients remains unexplored. Here, we outline the demographics, clinical features, and impact of PD in the Portuguese PRISM cohort. MethodsDescriptive analysis of the PRISM Portuguese cohort (80 patients) was performed, emphasizing socio-demographic data, anti-PD medication usage, PD impact on patients' lives and healthcare resources utilization. ResultsThe predominant comorbidities in the Portuguese PD cohort (55 % male; mean age 66.2 years; mean disease duration 8.8 years) included depression (26.3 %) and anxiety (26.3 %). Levodopa was the initial prescribed anti-PD medication for 88 % of patients. Among Portuguese PDP, dopamine agonists (DA), monoamine oxidase-B (MAO-B) inhibitors, and catechol-O-methyltransferase (COMT) inhibitors were used by 50 %, 44.4 %, and 18.3 %, respectively. Portuguese PDP experienced impaired quality of life (PDQ-39 score: 31.3 ± 16.8), various non-motor symptoms, namely sadness/blues (65.4 %), urinary urgency (63.5 %), high/low sex interest (57.7 %), while 56 % reported at least one impulse control behavior. Additionally, 30.8 % retired early due to PD and 31.8 % reduced hours in daily activities. Mental health appointments were attended by 31 %, primarily in psychiatry (19 %) and psychology (6 %), and psychotherapy. ConclusionThis study uncovers the burden of PD among Portuguese patients, revealing current treatment methods, impact on daily life and healthcare resources employed in Portugal. It emphasizes the need for personalized clinical strategies at national and international levels to improve long-term health outcomes and quality of life of PD patients.

A Nation-Wide Survey of Program Directors at a Large Health Care Organization: Prevalence and Perceptions of Resident Wellness Activities.

This study evaluated wellness programs in a large hospital network to determine residency program directors' (PDs) perspectives on their wellness programs' state, including wellness prioritization, frequency of wellness activities, and wellness' influence on decision-making across organizational levels. In 2021, 211 PDs were sent surveys on program policies, program implementation frequency, perceptions of the administration's ability to prioritize wellness, funding sources, and perceptions of resident wellness' impact on decision-making. Among 211 contacted programs, 148 surveys were completed (70.1%). The majority reported having wellness programs, committees, and funding. Fewer than 25% reported having a chief wellness officer. PDs perceived that fellow colleagues in their institution linked wellness to markers of institutional success to a greater extent than other available options (ie, Accreditation Council for Graduate Medical Education [ACGME] requirements, budgetary concerns, resident input, core faculty priorities, and education quality). Financial well-being was perceived as least connected to wellness. Perceptions of wellness were rated across 3 organizational levels: program, institution, and organization. Across all levels, ACGME requirements (31.0%-32.8%) and budgetary/financial concerns (21.9%-37.0%) were perceived as having the most significant influence on overall decision-making, whereas resident wellness was rated lower in influence (8.0%-12.2%). Most programs allowed residents to attend mental health appointments without using paid time off (87.9%) and while on duty (83.1%). The frequency of wellness activities varied greatly across programs. PDs reported challenges making resident self-care and personal development a priority and perceived resident wellness as having limited importance to decision-making at higher levels.

Implementation and evaluation of interprofessional overdose review team recommendations following intentional or accidental overdose events.

Drug overdose death rates in the United States remain high despite efforts to mitigate this risk. Many communities and hospitals across the country have implemented overdose review teams, including local overdose fatality review teams or postoverdose intervention programs, to address the opioid crisis. The goal of most of these teams is to identify missed opportunities or patient-specific interventions to prevent future opioid overdose fatalities. Few overdose review teams review a combination of both fatal and nonfatal overdose events. The Veterans Affairs Tennessee Valley Healthcare System implemented a novel overdose review team (ORT) that collaboratively reviews all overdose incidents regardless of fatality, intent, or substance involved. This practice description characterizes reported facility overdose events and patient-specific risk-mitigation strategies recommended by the ORT, highlights the implementation rate and time to implementation of ORT recommendations, and discusses potential areas for process improvement. This practice highlights the potential impact of a pharmacist-led, interdisciplinary ORT following accidental or intentional overdose events involving any substance or medication. Key patient-specific interventions implemented following ORT recommendations included overdose prevention education and naloxone distribution, prescribing of medications for opioid use disorder and/or alcohol use disorder, reducing medication supply to limit lethal means access, and facilitation of mental health and/or substance use disorder specialty appointments. Further research to evaluate clinical outcomes related to specific ORT interventions should be considered.

Implementing and evaluating a veterans crisis line quality improvement initiative: The safety planning pilot program.

The Veterans Crisis Line (VCL) is part of the U.S. Department of Veterans Affairs' suicide prevention mission. In 2021, VCL assessed the impact of a pilot implementation project of conducting six-part safety plans (SPs) instead of VCL's usual risk mitigation plan. VCL responders offered to complete six-part SPs with eligible callers. Parametric and nonparametric methods compared call characteristics and Veteran Health Administration (VHA) utilization of eligible callers, by SP completion. We forecasted the operational impact of VCL-wide implementation. 27.37% (N = 448/1,637) of calls to designated responders were eligible for SPs. Of those, 27.23% (N = 122/448) completed SPs. Common barriers were call interruptions and the veteran declining. Among veteran callers who use VHA, SP completers were more likely to accept clinical referrals and had more outpatient mental health appointments before and after their VCL call. Calls involving SPs had a call plus documentation time 175% longer than eligible calls without SPs (87.78 vs. 49.66 min). If SPs were implemented VCL-wide, this would require 3-5(4.12%) more responders per hour to maintain current VCL call answer speed. SPs are adaptable to VCL; however, implementation presents logistical barriers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact of Primary Care-Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups.

Receiving mental health services as part of primary care in the Veterans Health Administration (VHA) might increase engagement in specialty mental health care. The authors reexamined the association between primary care-mental health integration (PCMHI) and continued engagement in specialty mental health care for VHA patients and assessed differences by race and ethnicity. The study included 437,051 primary care patients with a first in-person specialty mental health encounter in 2015-2016 (no specialty mental health encounters in prior 12 months), including 46,417 patients with new PCMHI encounters in the year before the first specialty mental health encounter. Multivariable logistic regression assessed odds of follow-up specialty mental health care within 3 months of the first specialty mental health encounter. The dependent variable was care engagement (attending a second specialty mental health appointment); independent variables were whether patients were seen by PCMHI on the same day as the primary care appointment ("same-day access"), the time between PCMHI and first specialty mental health appointments, and race and ethnicity. PCMHI was associated with increased engagement in specialty mental health care for all patients, with a greater likelihood of engagement among non-Hispanic White patients. Same-day access to PCMHI was positively associated with care engagement, with no significant differences by race or ethnicity. PCMHI care within 3 months before a first specialty mental health encounter was associated with greater care engagement. PCMHI, especially same-day access to PCMHI care, may boost engagement in mental health care, although the study design precluded conclusions regarding causal relationships.

Telehealth Access and Substitution in the VHA

BackgroundIn response to COVID-19, the Veterans Health Administration (VHA) expanded telehealth availability, allowing veterans to receive care at home. We explore the extent of substitution of telehealth for in-person care among medical centers (facilities), providers, and patients. We explore the extent to which patient preferences drive telehealth utilization, and compare access to care (as measured by waiting times) for telehealth and in-person visits.MethodsWe use VHA electronic health records to identify scheduled outpatient mental health (MH) appointments from January 2019 through February 2023 focusing on care delivered by social workers, psychologists, and psychiatrists. For each quarter, we compute the proportion of completed appointments that were delivered via phone or video by each facility, provider, and patient and show the changes in these proportions before, during, and after the onset of COVID-19. To explore patient preferences, we match providers of patients with high rates of telehealth utilization and examine the extent to which those providers deliver in-person care. To examine access to care, we compute waiting times for in-person, video, and phone new patient appointments. We investigate differences between urban and rural patients, and patients of different ages.Key ResultsTelehealth for MH grew dramatically in the VHA after the onset of COVID-19. While some facilities provided more telehealth than others, all facilities (as of early 2023) provided some telehealth MH services. Approximately 86% of individual providers provided telehealth, with 27% scheduling MH appointments almost exclusively as telehealth appointments and 59% providing a mix. Patients exhibited more polarization, with 36% scheduling only in-person visits for almost all their MH visits and 56% of them scheduling exclusively telehealth, and only 8% of them utilizing a mix of modalities. Of those who exclusively received telehealth care, a majority of them utilized video (80%) over phone (20%). Take-up of MH among younger patients was higher relative to older patients. Urban patients used telehealth more than rural patients. Patient preferences rather than provider preferences drove utilization of patients who almost exclusively utilized telehealth. Between April 2021 and February 2023, the average difference in waiting time for in-person and video appointments was less than 1 day, with comparable appointment volumes, suggesting that the supply of and demand for in-person and video were not different enough to merit waiting longer. Telehealth was chosen over in-person more among urban and younger patients, as older and rural patients exhibited higher willingness to wait for in-person over video appointments. By contrast, appointment volumes and waiting times for phone appointments were lower across all groups, suggesting that phone may not be as substitutable for in-person visits in MH.ConclusionsWe find that the VHA has made telehealth widely available, providing access to many veterans. While telehealth utilization has increased, face-to-face care persists for MH services, suggesting that one modality may not serve all purposes and preferences for care. Patient preferences drive the modality decision among those who exclusively use MH care via telehealth. For those who persist in mostly utilizing in-person care, there may be various factors influencing those preferences such as issues with limited internet connectivity, language barriers, and digital literacy, especially for older and rural patients who utilize in-person care more than those who are younger and more urban. Further investigation is required to investigate the optimal mix of modalities which may allow for potential increases in patient satisfaction, quality of care, and clinic efficiency.

Fiduciary assignment as a potential intervention for substance use disorder: a retrospective chart review

ABSTRACT Background: Assignment of fiduciaries to veterans with disability payments is an intervention thought to improve quality of life; however, in veterans who use substances, a proportion of these payments may be misspent on drugs and/or alcohol. While fiduciary assignment may reduce funds available to purchase substances, clinical efficacy of this intervention in the management of substance use disorders has not been rigorously demonstrated. Objectives: The purpose of this study is to evaluate changes in clinical status before and after fiduciary assignment. Methods: This was a retrospective chart review of 50 (44 male, 6 female) veterans who were assigned a fiduciary and determined to have a substance use disorder (SUD). SUD-related data including outpatient and inpatient treatment, toxicology testing, and measures of psychosocial functioning for the three years before and after fiduciary assignment were extracted and compared. Results: Veterans were found to have higher rates of any form of employment after fiduciary assignment (Wilcoxon, Signed Ranked S-statistic = 0.22, pr = 0.02). Two changes in measures of substance use were found after fiduciary assignment. There was a reduction in positive screens for heroin (tstatistic = −2.7, p = .01), but an increase in positive screens for fentanyl (t statistic = 2.53, p = .02). There were some potentially clinically but not statistically significant trends in increased adherence with mental health appointments, number of medical hospitalizations, and rates of employment post-fiduciary assignment. Conclusions: Understanding the clinical impact of fiduciary assignment for veteran’s benefits is desirable but still pending at this time.

Health care barriers and perceived mental health among adults in Canada during the COVID-19 pandemic: a population-based cross-sectional study.

The perceived mental health of individuals in Canada who faced health care barriers during the COVID-19 pandemic is underexplored. We analyzed data collected March to June 2021 from adults who reported needing health care services within the past 12 months in the Survey on Access to Health Care and Pharmaceuticals during the Pandemic. Unadjusted and adjusted logistic regression analyses examined the associations between health care barriers (appointment scheduling problems, delaying contacting health care) and high self-rated mental health and perceived worsening mental health compared to before the pandemic, overall and stratified by gender, age group, number of chronic health conditions and household income tertile. Individuals who experienced pandemic-related appointment changes or had appointments not yet scheduled were less likely to have high self-rated mental health (aOR = 0.81 and 0.64, respectively) and more likely to have perceived worsening mental health (aOR = 1.50 and 1.94, respectively) than those with no scheduling problems. Adults who delayed contacting health care for pandemic-related reasons (e.g. fear of infection) or other reasons were less likely to have high self-rated mental health (aOR = 0.52 and 0.45, respectively) and more likely to have perceived worsening mental health (aOR = 2.31 and 2.43, respectively) than those who did not delay. Delaying contacting health care for pandemic-related reasons was associated with less favourable perceived mental health in all subgroups, while the association between perceived mental health and pandemic-related appointment changes was significant in some groups. Health care barriers during the pandemic were associated with less favourable perceived mental health. These findings could inform health care resource allocation and public health messaging.

Impact of Opt-Out Therapy Appointments on Resident Physicians' Mental Health, Well-Being, Stigma, and Willingness to Engage.

Background Health care professionals report higher levels of mental health symptoms, pandemic-related stress, personal health concerns, and reduced proactive coping, especially in recent years marked by the COVID-19 pandemic. As physician utilization rates of mental health and well-being services remain low, the need for preemptive care is crucial. Objective The present study sought to ascertain satisfaction, value, and attitude toward future mental health services among resident physicians. Methods Throughout the 2020-2021 academic year, resident physicians within 8 training programs at a large academic training hospital were offered single opt-out mental health appointments from hospital-funded, graduate medical education wellness staff at no cost to the resident. Appointments were conducted virtually during protected work time. A survey was sent to participants within 2 weeks following their appointment. Results A total of 153 residents (postgraduate years 1 to 7) were offered one-time opt-out appointments. Overall, 91 (59%) residents attended their opt-out appointments. Survey response rate was 57% (n=52). Respondents reported high levels of satisfaction (96%, 50 of 52), felt the appointment was worth their time (96%, 50 of 52), and felt that the opt-out appointments demonstrated training programs cared about their well-being (94%, 49 of 52). Nearly all residents (98%, 51 of 52) recommended appointments be offered to future residents. Most respondents (80%, 42 of 52) indicated that appointments increased their willingness to engage in mental health services. Conclusions Opt-out appointments increased resident willingness to engage in mental health services, positive attitudes toward future mental health services, perceived training program's care about their well-being, and reduced perceived mental illness stigma.

Assessing Access to Trauma-Informed Outpatient Mental Health Services for Adolescents: A Mystery Shopper Study.

The authors aimed to examine how access to trauma-informed mental health services in safety-net health centers varies by insurance type and race-ethnicity of the care seeker. In this mystery shopper study, three women (White, Latina, and Black voice actresses) called community mental health centers (CMHCs) and federally qualified health centers (FQHCs) (N=229) in Cook County, Illinois, posing as mothers requesting a mental health appointment for their traumatized adolescent child. Each health center was called twice-once in the spring and once in the summer of 2021-with alternating insurance types reported (Medicaid or private insurance). Ability to schedule an appointment, barriers to access, wait times, and availability of trauma-specific treatment were assessed. Callers could schedule an appointment in only 17% (N=78 of 451) of contacts. Reasons for appointment denial varied by organization type: the primary reasons for denial were capacity constraints (67%) at CMHCs and administrative requirements to switch to in-network primary care providers (62%) at FQHCs. Insurance and organization type did not predict successful appointment scheduling. Non-White callers were significantly less likely (incidence rate ratio=1.18) to be offered an appointment than the White caller (p=0.019). The average wait time was 12 days; CMHCs had significantly shorter wait times than FQHCs (p=0.019). Only 38% of schedulers reported that their health center offered trauma-informed therapy. Fewer than one in five contacts resulted in a mental health appointment, and an apparent bias against non-White callers raises concern that racial discrimination may occur during scheduling. For equitable access to care, antidiscrimination policies should be implemented.

The socio-demographics and clinical profile of patients referred to the GP liaison psychiatry service within a metropolitan Aboriginal medical service.

This study aimed to describe the social demographics and clinical profile of patients referred to the psychiatry service within the local Queensland metropolitan Aboriginal Medical Service (AMS). This was a retrospective cohort study of patients referred to the psychiatry service provided at three clinics of a metropolitan AMS, over an 18-month period. Medical records were accessed to determine demographic and diagnostic information. Diagnostically, 53% of patients had mood/anxiety disorders, 10% psychosis, 23% substance use and 14% with other diagnoses. There was approximately 50% non-attendance rate with no statistical difference between gender and age groups. The highest proportion of non-attenders within age groups was males 45-54years old. The patients needed to travel an average of 20km to attend the AMS. The high non-attendance rates, and proportionately more males within the age group 45-54years who were more likely to not attend their mental health appointments, suggested a target area for outreach services which have been implemented in the AMS. Some of the recommended solutions included confirming attendance the day prior and supporting with transport. This study highlighted the large distance that Aboriginal and Torres Strait Islander people must travel to access culturally appropriate service.

Differences in digital prenatal service utilization by self‐reported race

AbstractObjectiveThe objective of this study was to understand the use of supplemental digital prenatal services by race and ethnicity among pregnant people utilizing a comprehensive, employer‐sponsored digital health platform.Materials and MethodsWe conducted a retrospective cohort study of pregnant people enrolled in a comprehensive, employer‐sponsored digital health platform, assessing utilization of app‐based supplemental digital prenatal services by race and ethnicity. Care utilization included three categories: asynchronous utilization (e.g., article reads, videos); interactions with a care advocate, a trained care navigator; and provider interactions (e.g., messages and visits with a medical provider). Differences in service utilization by race and ethnicity were assessed using basic descriptive statistics with between‐group comparisons.ResultsOf 5662 users, 2362 (41.7%) were White, 266 (4.7%) were Black, and 1411 (24.9%) reported ‘prefer not to say’ for their race. More Black and Asian users sent messages to a provider and had provider appointments than White and Hispanic users (messages: White: 33.7%, Hispanic: 33.6%, Asian: 44.9%, Black: 45.1%, p &lt; 0.001; provider appointments: White: 49.8%, Hispanic: 43.3%, Asian: 52.4%, Black: 46.2%, p &lt; 0.001). More Black users accessed doula and mental health appointments than other racial groups.ConclusionsOur study demonstrates that pregnant people of historically marginalized groups use digital supplemental prenatal services as much or more than White patients. Digital prenatal services may be a promising avenue for improving care access and experience for patient groups that face the biggest barriers to care and worst maternity care outcomes.

“Pouring their heart out in Sainsbury’s”: qualitative study of young people’s, parents’ and mental health practitioners’ experiences of adapting to remote online mental health appointments during COVID-19

Background During the COVID-19 pandemic, technologies such as videoconferencing were used to deliver mental health appointments remotely online. For many people, this was a change from previous methods of mental healthcare receipt and delivery. We aimed to explore in-depth how practitioners, young people and parents in the UK experienced this transition.MethodsWe used qualitative methods to collect data, triangulating between free-text online survey data (n = 38), focus groups (n = 5) (3 young adult groups (total n = 11); 2 practitioner groups (total n = 7)), and semi-structured interviews (practitioners n = 8; parents n = 4). Data were analysed using reflexive thematic analysis.ResultsParticipants held mixed views about remote appointments, which were encompassed within the five themes of: home as clinic; disrupted therapeutic relationships; difficulties with engagement; uncontained risk; and scope of care provision. While appointments at home could be regarded as more comfortable, naturalistic and accessible, it was also recognised that remoteness compromised practitioner control with consequences for their ability to monitor patient engagement, manage risk and ensure confidentiality when others were present in the home. This could create an additional burden for parents as they tried to facilitate appointments but felt unsupported in this role. Relatedly, remoteness was seen to hinder interpersonal communication, formation of trust, communication of empathy and opportunities to observe body language, all of which were deemed important to building and maintaining effective therapeutic relationships. Despite this, others thought the anonymity of a remote exchange may allow earlier disclosure. There was disagreement as to whether remote provision narrowed or expanded the scope of practice.ConclusionsWhile some had positive views of remote mental health appointments, others found them challenging. Findings highlight key areas requiring attention and mitigation in future offerings of remote provision, namely: risk management, parental burden, and problematic engagement.

Using Nudges to Reduce Missed Appointments in Primary Care and Mental Health: a Pragmatic Trial

BackgroundMissed appointments (“no-shows”) are a persistent and costly problem in healthcare. Appointment reminders are widely used but usually do not include messages specifically designed to nudge patients to attend appointments.ObjectiveTo determine the effect of incorporating nudges into appointment reminder letters on measures of appointment attendance.DesignCluster randomized controlled pragmatic trial.PatientsThere were 27,540 patients with 49,598 primary care appointments, and 9420 patients with 38,945 mental health appointments, between October 15, 2020, and October 14, 2021, at one VA medical center and its satellite clinics that were eligible for analysis.InterventionsPrimary care (n = 231) and mental health (n = 215) providers were randomized to one of five study arms (four nudge arms and usual care as a control) using equal allocation. The nudge arms included varying combinations of brief messages developed with veteran input and based on concepts in behavioral science, including social norms, specific behavioral instructions, and consequences of missing appointments.Main MeasuresPrimary and secondary outcomes were missed appointments and canceled appointments, respectively.Statistical AnalysisResults are based on logistic regression models adjusting for demographic and clinical characteristics, and clustering for clinics and patients.Key ResultsMissed appointment rates in study arms ranged from 10.5 to 12.1% in primary care clinics and 18.0 to 21.9% in mental health clinics. There was no effect of nudges on missed appointment rate in primary care (OR = 1.14, 95%CI = 0.96–1.36, p = 0.15) or mental health (OR = 1.20, 95%CI = 0.90–1.60, p = 0.21) clinics, when comparing the nudge arms to the control arm. When comparing individual nudge arms, no differences in missed appointment rates nor cancellation rates were observed.ConclusionsAppointment reminder letters incorporating brief behavioral nudges were ineffective in improving appointment attendance in VA primary care or mental health clinics. More complex or intensive interventions may be necessary to significantly reduce missed appointments below their current rates.Trial NumberClinicalTrials.gov, Trial number NCT03850431.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form.

Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted. To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a). Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores. National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder). Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence. Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%. The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

Developing Marsha and Marian’s Neighbors: A Shared Housing Intervention to Address Homelessness among LGBTQ+ and Pregnant/Parenting Youth

Background: The aim of this paper is to describe the development of a shared housing model intervention that was designed to serve youth experiencing homelessness who are LGBTQ+ and/or pregnant/parenting. The intervention is built around two guiding philosophies: housing first and restorative justice. Methods: We engaged in a year-long planning process with an advisory group from 1 July 2021 through 30 June 2022. The advisory group is a partnership between Virginia Commonwealth University School of Social Work, seven young people with lived experience expertise, and members from four partner organizations, including local organizations serving LGBTQ+ youth. Results: Marsha and Marian’s Neighbors is designed to provide safe, comfortable housing for 12 months for 20 young people and their children if they have any. Participants will live in apartments where rent and utilities are paid for by the program for all participants. The program also provides money for arrears that may prevent the participants from being able to secure a lease, mental health appointments, legal consultations, and doula services provided by partners recruited by the planning team. Services are provided by staff and partners that are LGBTQ+ affirming and pregnant and parenting affirming. Conclusion: One of the most important lessons that we learned is the power of developing shared values in a novel intervention for LGBTQ+ youth. One focused intervention that supports both pregnant and parenting youth who identify as LGBTQ+ remains necessary. Paradoxically, LGBTQ+ people, particularly bisexual, lesbian, and queer cisgender women, are at an equal or greater risk of unplanned pregnancy. Both groups are vulnerable to housing instability independently, and those who live at the intersection of being LGBTQ+ and pregnant/parenting face an elevated risk for housing instability.

Mandated Limited Wait Times for Mental Health Appointments

Mandated Limited Wait Times for Mental Health Appointments